Medical Billing: Coding Challenges for PAs

In the present environment of billing compliance, it is imperative that physician assistants take an active role in the coding and reimbursement process. It is not something most of us were taught in PA school, but the stakes are high for PAs who face an 85% reimbursement rate from Medicare and some other third-party payers.

Many PAs feel that their worth cannot be measured only using productivity charts and reimbursement analyses. This is very true. The work PAs do is not always billable. You can't bill for time spent talking to a new mom on the phone for half an hour about her baby's feeding problems, or time spent filling out paperwork that helps a patient get medication on an indigent program that she would have otherwise done without. There are countless things we do that aid in patient care and satisfaction that have no CPT code.

But our employers are facing the bottom line, and we must be able to educate them on ethically maximizing reimbursement for our services so we can continue to do the job we love.

Here are some "coding challenges." See if you can determine the most appropriate billing for these scenarios that many of us face frequently in the office. The answers are below.

A 16-year-old girl with a history of wheezing now has an upper respiratory infection and has been short of breath for the last two days. You give her two nebulizer treatments, both with albuterol. She improves and you discharge her. The nurse spends 15 minutes instructing the patient on the proper way to use an inhaler. How would you code this?

A 30-year-old woman with a history of poorly controlled diabetes has been a passenger in a motor vehicle accident. She hit her head and has a laceration on her forehead. She complains of nausea and a headache. Her blood glucose is 220 mg/dL, and you have to adjust her insulin. You evaluate the head injury and order a computed tomography scan. You also suture the laceration. How would you code this?

A 25-year-old man comes to the office for a mole removal. You remove the mole, and three days later the patient returns with a back injury. What do you need to do to get paid?

A 66-year-old patient with Medicare as her insurance comes into the office for a physical and Pap smear. She also has hypertension, which is poorly controlled. You perform a physical examination, and during her history you discover she had a Pap smear last year, which was normal, and that her mother had uterine cancer. How do these points change how you would document and code this encounter?

In this case, first you should code the appropriate evaluation and management (E/M) code by your documentation. For this problem, you should document to substantiate a 99214. (E/M documentation is a whole other discussion, but be sure to have chief complaint, at least four elements of history of present illness, two to nine systems in review of systems, family history and past medical history and 12 elements in examination.)

Add modifier 25 to the E/M code to show a separate, identifiable service. Use code 94760 for the oximetry. Code the initial nebulizer treatment (94640) and the second (94640 with modifier 76 for repeat procedure by the same physician). The inhaler instruction is billed as 94664 with a modifier 59 added (designating a distinct procedural service). Then code J7618 (two units) for the albuterol.

Code the appropriate E/M for the head injury with a 25 modifier (separate identifiable service). Code the wound closure (documenting the size of the laceration). The head injury and wound closure are billed to the motor vehicle insurance. You then start a separate note for the diabetes management, and bill that to the patient's insurance company.

You need to add modifier 24 (unrelated E/M service by the same physician in the postoperative period) to the E/M code for the second visit. This is because the mole removal has a 10-day global period.

There are several points here that affect reimbursement. First, code the 99397 for the physical examination. Medicare does not pay for routine physicals, but if the patient schedules a physical, and you perform one, do not be tempted to help the patient out by coding a high level E/M instead of a preventive medicine code. This is considered fraud and carries serious consequences in an audit.

If you spend significant time on a specific problem during the physical, code the E/M code with a modifier 25 (separate identifiable service), link it to the ICD-9 for hypertension and document it separately. The patient will only be charged the difference between the charge for the physical and the Medicare allowable for the E/M code.

Next, code G0101 (Pap smear and pelvic examination) and Q0091 (preparation of Pap). Be sure to link both these codes to V72.3 (gynecologic exam) and V16.49 (family history of uterine cancer). This tells the payer that yearly screening is medically necessary. Otherwise, Medicare pays for gynecologic examinations every two years.

There are countless other scenarios to discuss. Some key points for PAs to remember:

	Document everything you do.
	Know E/M documentation guidelines.
	Understand "incident-to" rules.
	Learn how modifiers are used.
	Be as specific as possible with your diagnosis codes.
	Learn how to use 99050 and 99054 (after hours codes), 99058 (services provided on an emergent basis) and 99354 (prolonged service code).
	Work closely with your supervising physician and billing personnel to be sure your services are being billed appropriately. This is a team effort, and you can't afford to sit on the sidelines.
	Learn how modifiers are used.